Ritabelle Fernandes, MD, MPHAssociate Professor
Department of Geriatric MedicineJABSOM, University of Hawaii
This training/workshop is being conducted by Ritabelle Fernandes, MD, who is an Affiliated Regional Trainer for the National Task Group on
Intellectual Disabilities and Dementia Practices (NTG) and is authorized to use copyrighted and branded NTG training materials.
Dementia Capable Care of Adults with Intellectual & Developmental
Disabilities & Dementia
Disclosure - Sponsored by
Hawaiʻi Circle of Care for Dementia
Supported in part by grant No. 90ADPI0011-01-00 from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy. The grant was awarded to Catholic Charities Hawaii for the Alzheimer’s Disease Program Initiative.
National Task Group on Intellectual Disabilities & Dementia Practices (NTG)
• Coalition of interested persons and organizations.• Mission: Ensuring that the needs and interests of
adults with intellectual and developmental disabilities who are affected by Alzheimer’s disease and related dementias – as well as their families and friends – are taken into account as part of the National Alzheimer’s Project Act (NAPA).• To access resources, visit https://www.the-ntg.org/
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Risk of Dementia in ID
Most adults with ID are typically at no more risk than the general population.
Exception: Adults with Down syndrome are at increased risk!
• Younger (40’s and ‘50’s)• More rapid progression.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Dementia Prevalence: ID vs. DS
Intellectual DisabilityAge Percentage
40+ 3%
60+ 6%
80+ 12%
Down SyndromeAge Percentage
40+ 22%
60+ 56%
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Matthew P. Janicki and Arthur J. Dalton (2000) Prevalence of Dementia and Impact on Intellectual Disability Services. Mental Retardation: June 2000, Vol. 38, No. 3, pp. 276-288.
Dementia Prevalence: General Population
Alzheimer’s Association Facts and Figures Report, 2020
#s in U.S. vs. Hawaii
Alzheimer’s Association Facts and Figures Report, 2020
Tip of the Iceberg!
Hawaii figures do not include those who are undiagnosed
It’s estimated that approximately 60-80% go undiagnosed!
© Ritabelle Fernandes, MD. Copyright 2020. All rights reserved.
What is Down Syndrome (DS)?
• First accurate description of a person with DS was published in 1866 by an English physician - John Langdon Down.
• DS is a developmental disability – intellectual impairment and physical abnormalities.
• DS occurs 1 in 750 live births.• DS is caused by a genetic abnormality – an extra full or partial copy of
chromosome 21 (Trisomy 21). • Extra copy of genetic material alters the course of development and
causes the characteristics associated with Down syndrome.• common physical traits of Down syndrome are:
• low muscle tone, small stature, • an upward slant to the eyes, • and a single deep crease across the center of the palm• each person with Down syndrome is a unique individual and may possess
these characteristics to different degrees, or not at all
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Down Syndrome
https://www.drbeen.com/blog/chromosome-abnormality-down-syndrome/
Premature Aging in Down Syndrome
• Life expectancy has continued to increase for people with Down syndrome.• Aging increases risk for physical and cognitive
changes for people with DS.• Many individuals with DS age prematurely (age in
their 50s).• Adults with DS are at risk for diseases and changes
about 20 years earlier than the general population.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Plumeria
Heliconia
HibiscusOrchid
Bird of Paradise
Flowers
Adapted slide courtesy Dr. Terry & Michelle Barclay, Minnesota ACT on Alzheimer’s and The Barclay Group, LLC.
Alzheimer’s dementia
Vascular dementia
Parkinson’s dementia
Frontotemporal dementia
Lewy body dementia
Dementia
Adapted slide courtesy Dr. Terry & Michelle Barclay, Minnesota ACT on Alzheimer’s and The Barclay Group, LLC.
Alzheimer’s Disease
• Most common form of dementia.• Gradual onset.• Short term memory.• Generalized brain atrophy.
• Shrinks by 30% by time of death.
• Amyloid plaques and neurofibrillary tangles.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Why a Focus on Alzheimer’s?
§ Abrupt onset of seizure activity when there had been none in the past.
§ Incontinence when an individual has always been independent in toileting.
§ Short- term memory loss may depend upon the previous level of memory demands and reliance on memory in everyday life.
§ Sleep/wake cycle disruptions.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
*Just as in the general population, the course and symptom presentation is unpredictable and unique to the individual.
Alzheimer’s often presents differently in people with Down Syndrome.
Dementia Affects All Aspects of Functional Ability
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Memory Language skills
Ability to focus and pay
attention
Reasoning & judgment
Sensory perception
Ability to sequence
tasks
Traditional Screening Tools Not Useful
Traditional screening instruments for detecting dementia in the general population are designed for people with average baseline intelligence and are not useful for detecting cognitive impairment in adults with DS.
Example:• Mini-Mental Status Exam (MMSE)
Alternative:• NTG – EDSD
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
NTG Early Detection Screen for Dementia (EDSD)
Adapted from:• Dementia Screening Questionnaire for
Individuals with Intellectual Disabilities (Deb et al., 2007), and
• Dementia Screening Tool (adapted by Philadelphia Coordinated Health Care Group from the DSQIID, 2010)
Down Syndrome begin age 40 then annually.
Non-DS begin at age 50.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Tool & manual available online in multiple languages: https://www.the-ntg.org/ntg-edsd
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Continued
NTG-EDSD: 4 Key Sections
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Who Can Complete the NTG-EDSD?
• Any caregiver, either family or staff who is familiar with the person can complete the NTG-EDSD if they:• Have known person for a
minimum of 6 months• Have access to
information in the person’s record
How to best completethe form?
• Combine perceptions of function offered by several staff or family members.
• Use best judgment when responding to questions asking for impressions (e.g., health, function).
• Be truthful – don’t ‘hide’ problems to make a good impression
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Sources of Information
• Speak with:• family members• other staff who know the person
• Look through available medical records.• Look through program plans and personal files.• Get consensus among care team members on behaviors
and other performance factors.• Ask the person who is being screened.• Ask friends or other close persons.
A short digital video of the person performing certain tasks can also be helpful.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
I’ve completed the EDSD…now what?
• Review the form and see if there are any changes noted that are potentially of concern.• Talk it over with the individual’s key workers to ensure
agreement with the findings.• Discuss findings with the team and supervisor.• If there are concerns, make an appointment to have the
person further assessed.• Collate all of the information into useful packet• Assemble a list of medications being taken• Bring any digital video evidence of function or functional
problems
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Essentials of a Diagnostic Workup
• Rule out delirium – sudden confusion, inattention, medical emergency- UTI, impaction, pneumonia, medications
• Rule out depression/anxiety – has there been a recent significant life event?• Medication review – new meds, changes, interactions, anticholinergics*• History and physical (including psychiatric, personal, past medical and family histories
and mental state assessment)• Lab tests
Evidence supports the following tests:• Complete blood cell count • Serum electrolytes• Glucose • BUN/creatinine• Serum B12 levels• Thyroid function tests • Liver function tests• Celiac screening if DS (tTG-IgA test)
• MRI and/or CT scan (possibly)
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
The Three D’s
Dementia
Gradual over months to
years
Delirium
Sudden onset, hours
to days
Depression
Recent unexplained
change in mood that
lasts for over 2 weeks
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
CT Scan Brain
https://www.radiologyinfo.org/en/info.cfm?pg=alzheimers
Medications for Alzheimer’s
• Aricept* (Donepezil)
• Namenda** (Memantine)
• Exelon* (Rivastigmine)
• Razadyne* (Galantamine)
• Namzaric – NEW 2015. Extended release.• Namenda + Aricept• Approved for the treatment of moderate to severe dementia of the Alzheimer's
type• Capsule can be opened to sprinkle onto food
* Cholinesterase inhibitors are prescribed to treat symptoms related to memory, thinking, language, judgment and other thought processes in early to moderate AD. Delay worsening of symptoms for 6 to 12 months, on average, for about half the people who take them. ** Regulates the activity of glutamate, a different messenger chemical involved in learning and memory. Delays worsening of symptoms for some people temporarily.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
• Often used together for moderate to severe AD.• Statistically significant improvement in cognition
and global function for patients treated with NAMENDA XR 28 mg plus an AChEI compared to placebo plus an AChEI
Medications for cognitive decline in people with Down syndrome –
Cochrane Review 2015• Reviewed 9 randomized clinical control trials to study:
- donepezil, a medicine used to treat Alzheimer's disease (four studies)- memantine, a medicine used to treat Alzheimer's disease (two studies)- simvastatin, a (statin) medicine used to prevent heart disease (one study)- a mixture of antioxidants, including forms of vitamins C and E, and alpha-lipoic acid (one study)- acetyl-L-carnitine, a dietary supplement that has previously been used to treat dementia (one study)
• Generally, those who received the medicine did no better than those who received the placebo in any of the areas assessed in the studies. The areas assessed included general functioning (including memory and thinking, speech, mood and behavior); cognitive functioning (including memory, following what’s going on around you); adaptive behaviors (being able to do day-to-day tasks); or behavior problems (such as being irritable or aggressive).
• Overall, the quality of the evidence for effectiveness is low. Livingstone N, Hanratty J, McShane R, Macdonald G. Pharmacological interventions for cognitive decline in people
with Down syndrome. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD011546. DOI: 10.1002/14651858.CD011546.pub2
YOU may be in a position to be a health advocate…• You are given the responsibility to look after the
welfare of the adults that are in your program• You are a care manager• You work along with health personnel• You are a relative or family member• You are a friend or mate• You are involved in way that the health of adults
you work with can be your concern• You are engaged in some other capacity that gives
you access to the health practitioners
NTG Education & Training Curriculum on Dementia and I/DD. © NTG 2014. All rights reserved.
Four steps of health advocacy
#1 Observe #2 Report
#3 Prepare for the health
appointment
#4 Follow-up after the
appointment
NTG Education & Training Curriculum on Dementia and I/DD. © NTG 2014. All rights reserved.
Why is Dementia Health Care Advocacy Needed?
• Helping to speak for an adult with dementia when his or her cognitive impairment becomes a barrier to self-advocacy.• Ageism (prejudice or discrimination on the basis of a
person's age) by health care providers.• Assumption of automatic loss and decline as part of aging.
• Untrue but commonly believed.
• Assumption that all changes are due to dementia.• Especially in persons with Down syndrome.
• “Giving voice” on behalf of those who cannot. NTG Education & Training Curriculum on Dementia and I/DD. © NTG 2014. All rights reserved.
Caring for Someone with Dementia Requires a Shift in Thinking.
Rehabilitation Maintaining function, safety, and comfort
(Habilitation*)
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
*Habilitation is the term used by dementia professionals to describe the non-medical interventions considered best practices in day-to-day care, in creating good environments for ADRD patients, and within all their relationships and activities.
Key Concepts in Dementia Care
Reorientation
Validation
Redirection
Life Story
Maintenance support
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Adapted from Habilitation Therapy in Dementia Care. Paul Raia, PhD. 2011.
Key Concept in Dementia Care #1
Maintenance Support• Generally accepted as the best practice in dementia care.• Proactive approach
• A few minutes of pro-action can eliminate hours of reaction.• Focus is on support of remaining abilities.
• Respect changing needs of the person• Provide meaningful, failure-free activity. • Allow the person to do as much as they can for themselves but…be
aware that as the disease progresses the need for assistance will increase.
• Can reduce or eliminate difficult behaviors at all stages by reducing frustration, boredom, anxiety, fear, etc.• Can be done in all settings by all staff.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Focus on remaining abilities…not the losses.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Key Concept in Dementia Care #2
Life Stories
• The story is the essence of each person and should be documented over the lifespan. • When a person can no longer
tell their own story, activities related to storytelling can still be used to inform caregiving and plan activities.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Everyone has a life story that needs to be honored and respected.
Key Concept in Dementia Care #3
Validation Approach• Focuses on empathy and understanding.• Based on the general principle of validation…the
acceptance of the reality and personal truth of a person's experience… no matter how confused.• Can reduce stress, agitation, and need for medication
to manage behavioral challenges.• Forcing a person with dementia to accept aspects of
reality that he or she cannot comprehend is cruel.• Emotions have more validity then the logic that leads to
them.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Example of Validation
John (agitated): Someone stole my book.
You: "I'd be upset too, if that happened to me. I’ll help you look for it."
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
• Best practice in dementia care: Do not correct or try to “reorient” the person.• Requires staff to shift their care philosophy…
Example:
“What time is my mother coming?” (You know Ken’s mother died 20 years ago.) Which response is better:
a. “Your mother is dead, Ken. Your sister will pick you up at 4:00.”b. “She’ll be here in a little while. Let’s get a dish of ice cream while
we wait.”NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Key Concept in Dementia Care #4To Reorient or Not Reorient
Key Concept in Dementia Care #5REDIRECTION
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Distract AND Divert• Distract and redirect to minimize or avoid
outbursts and challenging behaviors. • Redirected with gentle distraction or by
suggesting a desired activity. • Providing food, drink, or rest can be
a redirection. • Smile, use a reassuring tone.
Example: Distract & Divert
It’s 4 am and raining. Harry wakes up and wants to go outside for a walk.
What should you do? Divert and Distract!Your response:
“Sure, lets go for a walk. But before we go I need to have a snack. My favorite snack is ice cream. What’s yours?”
• By refocusing their attention you can often redirect behavior.
• The goal is to distract the person long enough that their faulty memory will work to your advantage.
NTG Education & Training Curriculum on Dementia and I/DD. © NTG 2014. All rights reserved.
Behavior is Communication
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Behaviors are often triggered by:
© Kathryn Pears Copyright 2020. All rights reserved.
Dementia Communication 101
• Speak slowly and clearly.• Use short familiar words and phrases.• Give adequate time to respond.• Ask one question or give one direction at a time.• Break down complex tasks into simple tasks.• Avoid arguing or correcting.• When approaching a person come from the front and
maintain good eye contact.• Join – Validate – Distract.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Routine and Consistency
Established, consistent routines can be calming and reassuring, for both the person
with dementia and those around them.
• Dining same time, same place, same setting as much as possible• Community outings may become too challenging and need to be eliminated
on any given day or time• Plan activities ahead so everything is right there when needed• Create quiet corners within residential and program areas with objects that
are comforting and meaningful to the individual• Provide fluids & healthy snacks in areas as behaviors may be the result of
hunger and thirst
Structure the day
NTG Education & Training Curriculum on Dementia and I/DD. © NTG 2014. All rights reserved.
COVID-19
© Ritabelle Fernandes, MD. Copyright 2020. All rights reserved.
• Change of routine and habits• Challenges of physical distancing, PPE• Increased fear and confusion• Visitation limitation – nursing homes, hospitals• Testing issues• Ethical dilemmas• Grief and Loss
Adapt activities so they are “failure free.”
Adapt activities to suit the needs and capacity of the person.
Focus on simple activities which reinforce self-esteem while relieving boredom and frustration.
Emphasis is on remaining abilities, not losses.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Task
• Complex
• Simple steps
• Modified for increased impairment
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Early Stage
Middle Stage
Late
Environment
• New or unfamiliar setting, change in routine• Change in staff• Noise
• TV, radio, overhead paging system, people talking
• Lighting • People with dementia need 30% more light than we do.• Glare, shadows
• Large number of people• Over stimulating
• No orienting cues for way finding.• Bedroom, bathroom
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Dementia, Environment, & Safety
Remove obstacles in pathways to prevent falls.
Create an environment supportive for the caregiver as well as the
adult with ID and dementia.
Lock or disguise hazardous objects, areas.
Disguise doors for safe wandering.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Maximizing Location & Function
Environmental cues:Ex. Pictures on door
Familiar textures for matching.
Ex. On the seat for meals.
Lighting.Contrasting colors.
Reduce unnecessary stimuli.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Wandering: What can you do?
• Promote as exercise. Do not prevent the movement.• Keeping the landmarks the same as much as possible.• Create safe wandering spaces with opportunities for
sitting, drinking water and juices, snacks.• Disguise doors, locks, knobs of doors, use signaling
devices when door is opened,• Add meaningful activity within the wandering as much
as possible:• Music• Dance • Rhythm
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Wandering: What can you do?• Alzheimer’s Association Safe Return Program
www.medicalert.org/alz
• Rule out pain, physical discomfort, medications, or other unmet need as cause.• Try: Bright light therapy,
short naps during day, keep room dark and quiet, use red or amber bulbs in night lights.
NTG Education & Training Curriculum on Dementia & I/DD. © NTG 2014. All rights reserved
Disrupted Sleep Wake Cycle
Dementia & VisionFactors that may be affected by AD:
• Visual field reduced about 3 feet from the floor• Depth perception• Color contrasts• Acuity• Motion versus stationary objects• Object identification• Delayed recall to visual stimulation• Figure-ground differentiation• Size and shape• Visual memory
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Suggestions for Modifications
Reduce visual clutter.
Organize visual clutter into specific appropriate places.
Clearly identified walking paths.
Reduce glare.• Use matted and low gloss surfaces.• Floors with texture and not shiny surfaces.• No-gloss waxes and cleaning products.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Hearing Challenges• Hair cells in the ear receive the auditory stimuli,
transmitted to the neurons of the brain, etc.• Increased incidence of hearing loss with dementia.
• One study reported 83% of people with early to mid-stage dementia.
• Continual noise pollution in our environments.• Impairment in reception and response to stimuli.• Impairment in comprehension (underlying cause?).• May need examination to assess for ear wax.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Suggestions for Hearing ImpairmentReduce background noises (fans, radios, TVs, appliances).
Add soft materials such as carpeting whenever possible.
Visual and/or physical cueing along with auditory information.
Staff awareness:• Simple, short, one direction or piece of information at a time. • Speak at eye level after gaining eye contact.• Wait longer for the response than in the past.• Hearing aid batteries are tiny and need to be replaced frequently.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Example of a Residence for Adults with ID
Lack of color contrasts, significant shadowing, and glare increase likelihood of difficulty functioning for the adult with ID and dementia.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
© Ritabelle Fernandes, MD. Copyright 2020. All rights reserved.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Caregivers
NTG Education & Training Curriculum on Dementia & ID. Copyright 2014. All rights reserved.
Extent of Family Caregiving for People with ID (Braddock. 1999).From the 1930s until the 1990s, the mean age at death for persons with ID rose from 18.5 years to 66.2 years.• 75% live with a parent, spouse, or other family
caregiver, • 13% live alone, and • Only 12% live in a residential facility. • Approximately 25% of those caregivers are aged 60+
with 35% aged between 41 and 59. • The projected population growth in the 65+ age group,
due to the aging baby boomer generation, will significantly increase the number of aging caregivers in the years ahead.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Unique Challenges Caring for an Adult Child with ID (and Dementia)
General PopulationAverage period of time that a caregiver provides assistance to a spouse or older family member with a chronic illness:
4.5 years
(National Alliance for Caregiving & AARP, 1997).
Parents with Child with IDCaregiving can last for 60 years or more.For a vast majority of family caregivers…
lifelong career
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
ID & Dementia:A Special Risk
Aging caregivers for people with ID may be at special risk because of:• age-related health and behavioral declines in the
aging care recipient and caregiver, • extensive duration of the caregiving role, and • concerns about the long-term care of the care
recipient• Who will care for their child if/when they die?• How will they pay for care?• Who will provide it?
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
Connect to Resources
• Alzheimer’s Association• 24/7 Helpline | 800.272.3900 www.alz.org/hawaii
• Hawaii Aging & Disability Resource Center (ADRC)• 643-ADRC (2372) | TTY line: 643-0889 • www.hawaiiadrc.org
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.
End-Of-Life Care
• Hospice CriteriaAdvanced Dementia evidenced by functional decline, weight loss, infections
• Hospice Providershttps://kokuamau.org/hospice-providers/
• Resourceshttps://kokuamau.org/kokua-mau-resources/advanced-dementia-resources-and-issues/
© Ritabelle Fernandes, MD. Copyright 2020. All rights reserved.
Importance of Health Care Advocacy
There are often interventions that
can make a difference in
quality of life and health.
Staff and family are the experts about individuals with ID.• To recognize current
changes and symptoms knowing the person across the lifespan is the best resource.
Health care is an art,
not a science!
NTG Education & Training Curriculum on Dementia and I/DD. © NTG 2014. All rights reserved.
BibliographyBishop KM, Hogan M, Janicki MP, et al. Guidelines for dementia-related health advocacy for adults with intellectual disability and dementia: National Task Group on Intellectual Disabilities and Dementia Practices. Intellect Dev Disabil 2015 Feb;53(1):2-29.
Moran JA, Rafii MS, Keller SM, Singh BK, Janicki MP. The National Task Group on Intellectual Disabilities and Dementia Practices consensus recommendations for the evaluation and management of dementia in adults with intellectual disabilities. Mayo Clin Proc 2013 Aug;88(8):831-40.
Matthew P. Janicki and Arthur J. Dalton (2000) Prevalence of Dementia and Impact on Intellectual Disability Services. Mental Retardation: June 2000, Vol. 38, No. 3, pp. 276-288.
NTG Education & Training Curriculum on Dementia and ID. Copyright 2014. All rights reserved.